Alcohol Use and the Pre-exposure Prophylaxis Continuum of Care Among Men in Rural South Africa: Results from a Longitudinal Study

Alison C Castle; Jacob Busang; Jaco Dreyer; Carina Herbst; Nonhlanhla Okesola; Natsayi Chimbindi; Thembelihle Zuma; Jana Jarolimova; Judith A Hahn; Christina Psaros; Sheela V Shenoi; Maryam Shahmanesh; Mark J Siedner

doi:10.1007/s10461-025-04694-y

Alcohol Use and the Pre-exposure Prophylaxis Continuum of Care Among Men in Rural South Africa: Results from a Longitudinal Study

AIDS Behav. 2025 Apr 5. doi: 10.1007/s10461-025-04694-y. Online ahead of print.

Authors

Alison C Castle^{1

2

3}, Jacob Busang⁴, Jaco Dreyer⁴, Carina Herbst⁴, Nonhlanhla Okesola⁴, Natsayi Chimbindi^{4

5

6}, Thembelihle Zuma^{4

5

6}, Jana Jarolimova^{7

8}, Judith A Hahn⁹, Christina Psaros^{8

10}, Sheela V Shenoi¹¹, Maryam Shahmanesh^#^{4

5}, Mark J Siedner^#^{4

7

8

6}

Affiliations

¹ Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa. accastle@mgb.org.
² Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA. accastle@mgb.org.
³ Harvard Medical School, Boston, MA, USA. accastle@mgb.org.
⁴ Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa.
⁵ University College of London, London, UK.
⁶ University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa.
⁷ Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA.
⁸ Harvard Medical School, Boston, MA, USA.
⁹ Division of HIV, ID, and Global Medicine, University of California San Francisco, San Francisco, USA.
¹⁰ Behavioral Medicine Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.
¹¹ Yale University School of Medicine, New Haven, CT, USA.

^# Contributed equally.

PMID: 40185960
DOI: 10.1007/s10461-025-04694-y

Abstract

Despite freely available oral HIV pre-exposure prophylaxis (PrEP), HIV incidence among young men in South Africa remains high. This study explores the impact of alcohol use on PrEP initiation and continuation among South African men. We performed a secondary data analysis from a trial involving men aged 16-29, randomly selected in KwaZulu-Natal. Participants were referred to sexual health services, and those who were HIV negative and sexually active were offered oral PrEP. Alcohol consumption was categorized using AUDIT-C criteria as no/low risk (0-3) and hazardous alcohol use (4-12). Primary outcomes were PrEP initiation and continuation, defined as refilling prescriptions for ≥ 4 months. Logistic regression models adjusted for clinical and demographic confounders estimated relationships between PrEP initiation/continuation and alcohol use. Among 325 men analyzed, average age was 22.9 years (SD 3.6), with 146 (45%) reporting hazardous alcohol consumption. PrEP initiation was greatest among the hazardous/very-high risk group (40%), with the lowest uptake among men who do not use alcohol (17%). In multivariate analyses, those with hazardous alcohol use remained more likely to initiate PrEP compared to those with no/low risk alcohol use (aOR 1.96, 95%CI 1.13-3.40; p-value = 0.017). Only 27% (24/88) remained on PrEP at 4 months, with continuation similar between alcohol use groups (aOR 1.56, 95%CI: 0.47-5.12, p = 0.47). Hazardous alcohol use is prevalent among men in rural South Africa and associated with increased PrEP initiation. However, overall PrEP continuation was low and consistent across alcohol use levels. Hazardous alcohol use should not deter PrEP implementation efforts to engage young men.

Keywords: Alcohol; HIV prevention; Men; Pre-exposure prophylaxis; Retention; South Africa.

Abstract

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